Hypospadias is one of the most common congenital anomalies encountered in pediatric surgical practice. It is a condition wherein the urethral opening is ectopically located on the ventral aspect of the penis. It is frequently associated with ventral penile curvature. The most common type of hypospadias in our study was coronal, which was seen in 34.2% (n=13) of the cases, which is consistent with the findings of a study by Gamal Al-Saied et al.
Surgical intervention for hypospadias can be performed at any age; however, most authors recommend operative intervention at 6–18 months. The mean age of surgery in our study was 3.1±0.3 years and 3.5±0.3 years in Group A and Group B, respectively. Although it is one of the most common surgeries performed by pediatric urologists, the high rates of complications, especially UCF, make it a challenge. In fact, multiple surgeries are required in more than 15% of children with hypospadias .
The most common complication which requires reoperation is UCF. Reoperations and complications lead to a financial burden on the family, surgery and anesthesia-related complications, and long-term psychosexual issues. Alternate measures, including temporary re-catheterization and the use of tissue sealants, have been explored to reduce the complication rate of hypospadias surgery.
Butyl and octyl cyanoacrylate has been used extensively in the primary closure of pediatric surgical wounds, including sutureless circumcision and lacerations . Tsur et al were the first to describe butyl cyanoacrylate in combination with sutures for hypospadias repair in the 1970s, which was later reinforced by Lapointe et al in their experience with butyl cyanoacrylates for fistula closure after hypospadias repair[10,11]. The most important advantages of using cyanoacrylate adhesive are its ease of application, tensile strength, and hemostasis conducive to preventing complications. In the present study, all patients underwent urethroplasty by traditional suturing technique. Group B patients also underwent adjunctive adhesive application. The glue used in the present study was n-butyl cyanoacrylate.
The most common complications following hypospadias repair are the occurrence of UCF, edema, and penile torsion. In our study, the frequency of development of UCF was 25% (n=5) in Group A and 16.6% (n=3) in Group B. This is in concurrence with a study by Saroj C Gopal et al, where a total of 120 patients with proximal penile hypospadias were studied, in which it was found that 10% of patients in whom fibrin glue was used developed UCF. In contrast, 32% of the patients developed UCF in whom no glue was used.
Four comparative studies were included in the meta-analysis performed by A Singh et al. They observed that the use of adhesives did not statistically reduce overall complication rates, which is consonant with the index study (RR 0.63, p-value = 0.13). However, they found a significant reduction in urethrocutaneous fistula (RR 0.37, p = 0.003), complications involving the neo-urethra (RR 0.15, p =0.004), and wound-related complications (RR 0.57, p = 0.008).
In another study by GA Gonzalez et al, UCF was significantly lesser with adhesive than in the suturing-only group (10% vs. 41%). We also observed that UCF as a complication occurred in fewer patients where the adhesive was used as an adjunct (25% in Group A and 16.6% in Group B).
In our study, the incidence of meatal stenosis was 10% (n=2) in Group A and 5.5% (n=1) in Group B, which was relatively higher vis-a-vis the study by Yuhao Wu. et al where the incidence was 2.1%.. The incidence of necrosis was found to be 5% in Group A in our study. A similar study by Hosseini et alrevealed necrosis in 10% of patients who underwent urethroplasty with adjunctive adhesive. None of the patients in our study had penile torsion following surgery, while the incidence of penile torsion following urethroplasty ranges from 1.7% and 27%, according to studies conducted worldwide.
Lapointe et al, in their study, primarily used adhesive to successfully treat six out of 13 patients with postsurgical UCF. In our study, we also managed four patients with UCF by using adhesive as an adjunct (Group B), of whom two cases recovered without any recurrence.
The present study's findings, in general, corroborate with studies conducted worldwide. However, as discussed, certain findings were at variance with the results and conclusions of a few other studies. These differences could result from a smaller sample size, differences in the surgical techniques followed amongst different institutes, and a relatively shorter follow-up period of our study. In our study, we did not encounter any form of allergic or adverse hemodynamic effects from the glue. LCCA tissue adhesive proved to be a safe and effective solution to this overwhelming number of complications.